SCHOOL/DAYCARE CHICKENPOX REPORTING FORM 

Upon notification of each case of chickenpox: 

1.Complete this form. The form can be found on online at www.wechu.org (search wordchickenpox).
2.Fax completed form to 226 783-2132 (within one business day).


3.Distribute the “Exposure to Chickenpox” letter (received by email from the health unit).



Date reported to school/daycare: 

Information obtained from: 

Name of school/daycare reporting: 

Is the school attached to a daycare? 

No ☐ Yes ☐ 

Administrator’s name: 

Contact number: 

Administrator’s email: 

Student date of birth: (yyyy/mm/dd) 

Age: 

Sex: 

Name of student (First, Middle, Last):


Address:

(Street, City, Postal Code)


Name of parent/guardian: 

Home phone:

Alternate phone:

Language spoken at home: 

Last day attended school/daycare: (yyyy/mm/dd) 

Does the student attend latchkey? 

No ☐ Yes ☐ 

Collection of information conforms to the Health Promotion and Protection Act, R.S.O. 1990, c. H.7, s. 28 and the 
Infectious Disease Protocol, 2016. Please contact the Windsor-Essex County Health Unit for further information. 

*Once the Windsor-Essex County Health Unit has confirmed receipt of this fax, pleasedestroy this form in a confidential manner.

Reportable Diseases\Chickenpox/June 2021